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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445202741
Report Date: 11/10/2022
Date Signed: 11/10/2022 01:38:12 PM

Document Has Been Signed on 11/10/2022 01:38 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:SANDPIPER VILLAFACILITY NUMBER:
445202741
ADMINISTRATOR:OLIVARRIA, ALICIAFACILITY TYPE:
735
ADDRESS:418 SUMNER AVENUETELEPHONE:
(831) 818-7981
CITY:APTOSSTATE: CAZIP CODE:
95003
CAPACITY: 6CENSUS: 6DATE:
11/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:42 PM
MET WITH:Rona VictoryTIME COMPLETED:
01:38 PM
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Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced annual inspection on 11/10/2022 at 10:10am. LPA met with facility Lead Staff Member Rona Victory (S1). Administrator Alicia Olivarria was unable to attend the inspection and gave S1 permission to sign on her behalf.

LPA toured the facility, including living room, kitchen, dining room, 4 client bedrooms, 3 bathrooms, back yard, storage room, and staff office. All staff members observed to be wearing masks. S1 confirmed that all staff and residents have been vaccinated.

Facility infectious control plan has already been submitted. No prohibited items noted in resident rooms. All emergency exits noted to be clear of obstruction. All rooms in facility noted to be clean and well maintained. Hand sanitizers, soap, and paper supplies were observed to be available. At least 2 days' supply of perishable food and at least 1 week's supply of non-perishable food was observed on the premises. Fire extinguisher observed to be inspected in January 2022. Smoke/carbon monoxide detectors tested and observed to be operational.

Facility observed to have designated entry point. Staff took LPA's temperature and screened for symptoms. 30 day supply of PPE observed. All shared restrooms stocked with paper towels. Water temperature observed to be 117.3 *F. Hand washing signs observed in all bathrooms. Facility temperature observed to be 68*F. Social distancing signs observed to be posted in all public areas.

No deficiencies cited during today's visit. This report was reviewed with Lead Staff Member Rona Victory and a copy of the signed report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Ryker Heberle
LICENSING EVALUATOR SIGNATURE: DATE: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/10/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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